Professional collaboration is challenging when resources are minimal and communication is compromised, as is the case in many parts of Africa. In this article, a group of health professionals from the North-West Region of Cameroon report on efforts to improve within-profession, interprofessional and interorganisational collaboration in eye care services. The article describes what collaboration is in healthcare and how it benefits patients, professionals and health systems, using eye and vision care services as an example. Obstacles such as the absence of a coordinated eye care system and the lack of institutional support are described. Seven successful strategies to promote collaboration in this context are identified, and their applications in this context are described. These strategies are as follows: being committed to collaboration; being client-focused; supporting interprofessional and continuing education; embracing new technologies; building relationships between professional groups; building relationships with organisational administrators; and building relationships in healthcare systems. Three additional aspirational strategies are: developing regional healthcare programmes; developing professional and continuing education programmes; and developing collaborative patient and public education. By providing this open report, the authors aim to stimulate discussion about how collaboration and cooperation improve quality healthcare services and support professional career development.
Professional collaboration can be extremely challenging in settings where resources are minimal and there are many demands on time, energy and money. This article reports on how a group of health professionals in a low-resource African setting realised their efforts to improve interprofessional collaboration, addressing interprofession and interorganisational collaborative practices despite many challenges. We begin by describing what collaboration is and briefly review the literature about why collaboration is important in health and vision care, regardless of the context. We then use a case study approach to describe the current practice situation in the North-West Region of Cameroon, providing a focus on the efforts being made to improve collaborative practice among vision care professionals in this region. We identify the obstacles encountered as well as possible solutions and describe the ways interprofessional collaboration has been enhanced.
Writing this article was a collaborative exercise that provided an opportunity to further reflect on what collaboration looks like in our African context. The article developed out of discussions that were part of the Groups for Rehabilitation and Inclusive Development (GRID) Network, a community of practice model that supports professional development in the region.
Some professional groups and settings use the term ‘patient’ while others prefer ‘client’. In this paper, we use the terms interchangeably, to mean the person receiving service.
The World Health Organization recognises the importance of collaboration and provides this definition of what it looks like in healthcare practice:
Collaborative practice in health-care occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers, and communities to deliver the highest quality of care across settings. Practice includes both clinical and -non-clinical health-related work, such as diagnosis, treatment, surveillance, health communications, management, and sanitation engineering. (p. 13)
Collaboration in healthcare is evident when healthcare professionals communicate well with each other, assume complementary roles to cooperatively work together and share responsibility for problem-solving and decision-making to formulate and carry out plans for patient or client care. Specific collaborative activities include sharing of information, discussion of complicated cases, and referrals to colleagues.
There are many benefits to collaboration, and research evidence that supports these benefits is building. Collaborative work among health professionals has been shown to improve patient care and outcomes, improve the skills and knowledge of professionals, and reinforce good and necessary communication, leading to better and more cost-efficient health systems.
It is also useful to examine what happens when collaboration does not turn out well. When healthcare professionals working on a team do not communicate effectively, patient safety is at risk: there can be a lack or misinterpretation of critical information, unclear orders or overlooked changes in patient status.
There have been calls for collaboration from many health leaders external to our Cameroon setting. For example, the Framework for Action on Interprofessional Education and Collaborative Practice, which was published in 2010 by the World Health Organization,
When collaboration is recognised as vital in low-resource settings, it can be difficult yet possible to implement within and across organisations by giving attention to key factors. Sitas et al.
Within Cameroon, calls for improved collaboration have been made by Fokunang et al.
The North-West Region is one of Cameroon’s ten regions. The impact of the social determinants of health are very evident here.
There is little research about the roles or collaborative practices of eye care professionals in the North-West Region. We return to the five areas identified by the WHO –
Anecdotally, we are aware that collaboration between eye care professionals appears to be ineffective because many professionals do not know each other, and structures and systems are not in place to foster collaboration. There are few processes in the region that support shared decision-making. The natural and built environments present barriers: communication by phone or Internet is expensive, with poor- quality networks.
There is a perception that collaboration is often not supported by organisations and governments because it is not seen as a good use of funds and time. Related to the few health economic studies or innovative vision programmes in our region, little is said by leaders about professional collaboration, either for professionals of the same field or interprofessionally. When it is mentioned, collaboration appears to refer to different professionals coming together for a common goal, usually a short-term project and often as the result of external funding.
The social setting and professional practice culture also impact how collaboration is carried out in the region. For many of us, collaboration is not part of the professional culture (as we identify in more detail further). Anecdotally, we see that people generally feel the need to protect ‘organisational secrets’ and will want to be the sole owners or providers of a particular service, thereby regarding collaboration as betrayal of the organisational culture and going against the explicit and implicit organisational hierarchy, especially if they have not received explicit authorisation from their superiors. Many professionals will only meet with others if compelled to by government interventions, for international days of observance or for workshops in which monetary compensation is provided. And at these times, what is presented about an organisation and the reports about what was done that are given back to the organisation are generally somewhat censured. This circumspection in itself is not negative, but the quest to protect the organisation rather than to improve patient outcomes can pave the way for lack of effective collaboration on how to improve services. This kind of cautious professional culture is detrimental to quality healthcare in particular and to professional practice and growth in general as it sometimes results in duplication of services in some areas while other areas remain largely underserved. For example, this duplication occurred in the region in 2015, when a lack of professional collaboration between Presbyterian Eye Services and Baptist Eye Services resulted in duplication in eye outreach programmes in some communities, and for apparent reasons of limited resources, other communities did not have access to any eye outreach services.
Despite the obstacles, there is a growing and committed number of vision care providers across organisations making collaboration, cooperation and referrals a priority in their work. Without cooperation and collaboration, it is difficult to offer patients quality healthcare. This group has become a network founded on the belief that it is beneficial for professionals working in the same field, such as vision care, to learn together. The members of this emerging network share a determination to work ‘hand in glove’ to continue to make improvements; our initial successes as a collaborative network are what prompted us to write this article. We present these examples of eye care professionals to illustrate how practitioners have found ways to collaborate in a low-resource setting where professional collaboration is not well encouraged by existing systems.
The population of the region is estimated to be about 1.8 million people, with approximately 2.3% to 3.0% experiencing moderate or severe bilateral visual impairment.
Having looked at the situation related to visual impairments and blindness, we now provide more information specifically about vision care in the North-West Region. We are aware of several eye care services in the region but not of any recent research specifically focused on studying these services. Services are provided by government and non-governmental organisations. There are seven divisions in the region with four ophthalmologists. At the time of writing, there are two ophthalmologists in Kumbo, Bui Division, and two at Mbingo Baptist Hospital, Boyo Division. The remaining five divisions had no ophthalmologists. Bamenda (in Mezam), the capital of the region, with close to half a million people, does not have an ophthalmologist.
In terms of non-governmental organisations, there are both faith-based and private organisations. It is difficult to know how many organisations carry out such activities because of the lack of a central listing. The faith-based institutions (Baptist, Presbyterian, and Catholic health organisations) provide inpatient and outpatient care and community outreach programmes. A number of other non-governmental organisations such as SOHDECAM (Solidarity Health and Development Effort Cameroon,
In the region, there is no school for eye health professionals, and there is no formal training programme for ophthalmic nurses. Therefore, getting ophthalmic professionals has been a challenge. Ophthalmic nurses receive training outside of Cameroon, usually in Ghana, Nigeria or Tanzania, and some go to India for their training. Some organisations, such as the Presbyterian Health Services and the Cameroon Baptist Convention (CBC) Health Services, train their own staff. The Presbyterian Health Services have in-service training for ophthalmic clinical officers and make use of the countries mentioned to train their ophthalmic nurses.
The CBC Health Services trains three categories of eye staff:
The ophthalmic medical assistant (OMA) programme is a 3-year training course. Ophthalmic medical assistants are trained to assist the ophthalmologist by doing some of the work the ophthalmic nurses do in the absence of an ophthalmic nurse, as a formal approach to task shifting. The basic requirement for training is an A-Level (Advanced Level) certificate.
The assistant ophthalmic medical assistant (AOMA) programme is a 2-year training programme, with the minimum requirement for entry being an O-Level (Ordinary Level) certificate. The AOMAs are trained to do some of the things that the OMAs do and usually work under the OMAs.
Ophthalmic auxiliaries are trained locally at the CBC Hospital at Mbingo.
As we examined our collaborative practices and aspirations across these different professional groups, we identified several challenges and obstacles, which we summarise in
Obstacles to collaboration.
| Obstacle to collaboration | Effects on practice |
|---|---|
| Lack of a coordinated regional eye care programme. | Makes it difficult to harness efforts towards similar goals. Professionals fail to provide services (where others in different countries have succeeded) instead of moving ahead. Professional discouragement. |
| Lack of knowledge about how to collaborate across organisations. | Information is not shared; professionals do not learn about new techniques and programmes. |
| Lack of knowledge and infrastructure to make referrals. | Patients are not referred when they should be. |
| Fear |
Referrals that should be made are not made. |
| Fear of losing patients to other institutions. |
Extra time and expense for patients as they cannot bring results from one centre to another, for example, when a patient is referred to another institution for a particular lab test or eye test there can be duplication of costs such as visual field test or fluorescein angiography. Patient is required to pay a consultation fee and go through the whole process a second time. |
| Lack of institutional infrastructure and hospital policies that do not give room for collaboration. | A service will not accept results from other providers. |
| Lack of collaboration with other doctors. |
Mutual sharing of information about how to improve patient outcomes does not happen. |
| Generational conflicts: |
Beginners do not get the necessary input to let them develop professionally. |
| Trained cataract surgeons are not allowed by some ophthalmologists to perform cataract surgeries, despite the backlog, for unknown reasons. | Lack of support for trained professionals increases the backlog because there is no task shifting where it is supposed to be applied. Others will not want to go for training when they have the opportunity because they are afraid they will not be granted the permission to practise when they return. |
| Low pay and lack of commitment to professionalism. | Practitioners spend time on other activities rather than doing the job they are supposed to be doing. Some engage in private practice and take patients for surgery in other institutions where they can make more money. |
| Pride and fear of being seen as not knowledgeable; unwillingness by some less experienced to learn new skills from the more experienced because they are too proud to accept learning. | Poor quality of eye care services, poor surgical outcome and patients lose confidence in eye doctors. |
| Lack of opportunity to develop professional skills. | Eye care provider starts searching for other jobs in other institutions or resigns. |
As described, in the absence of a coordinated or national eye care programme in the North-West Region, eye care is provided by a range of organisations and traditional practitioners, including some ‘quacks’. No regional eye care plan exists, and each organisation works independently of other care providers. The vision services are not regulated, and each of these providers has their own interests and approach to eye care delivery and referral protocol.
This lack of coordination and referral system hampers collaboration. With no referral system, patients suffer the costs of going out of the region, whereas a specialist may be available in another organisation in the region. For example, a general practitioner or a chief of centre in one town might refer patients to the regional hospital and not to a service that is closer and more convenient to the patient because of the wish to support the public system rather than a private provider. Likewise, nurses in a faith-based health centre might refer a patient out of the region to support their own organisation.
Collaboration takes skills in communication, commitment to good outcomes and discussion of errors, and ability to deal with conflicts. It appears that the existing professional training centres and health professional schools do little or nothing to train students in collaboration. Once in practice, there are few professional development opportunities for healthcare professionals to learn about how to work in teams and how to develop skills in collaboration.
Collaboration takes good communication – meetings, phones, emails and the use of other technologies. Often our institutions do not provide good phone lines, Internet connections or computers. Communication, especially across organisations, becomes very difficult. In addition, when there is a shortage of specialised equipment, collaboration has the potential to improve the situation because a specialised machine, for example, can be more fully used. However, when professionals are not working together, equipment might not be obtained or could be underutilised. Patients who could benefit do not receive the services they deserve. If eye care specialists within the region worked more collaboratively to obtain equipment, the current situation of having no or limited equipment to offer some specific care to eye patients could be improved.
Lack of communication creates situations where medical errors can occur. These errors have the potential to cause severe injury or unexpected patient death. Medical errors, especially those caused by a failure to communicate, are a pervasive problem in today’s healthcare organisations. According to the American Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations), if medical errors appeared on the National Center for Health Statistics’ list of the top ten causes of death in the United States (US), they would rank number 5 – ahead of accidents, diabetes and Alzheimer’s disease, as well as AIDS, breast cancer and gunshot wounds.
Competition between eye care providers hampers collaboration when practitioners do not want to refer a patient to another facility. Anecdotal reports are that some providers believe that referrals will reduce the income of their home institution. Even though they are aware that other professionals have specific skills and areas of practice, such as occuloplasty, vitro retinal services, paediatric ophthalmology, squint surgery, low vision services and community identification of vision problems, they will not want to refer to these specialised services, thinking that they will lose out on financial gain or because they are too proud to inform a patient that services would be provided better by someone else. Sometimes the programme administrators, who are non-medical staff, question referrals because they know that the service fees will go to the second organisation and that a referral may give the impression to patients that the staff at the referring organisation are incompetent. Therefore, the patient may end up being poorly managed.
Some church leaders caution their congregations not to patronise the services of other faith-based organisations. An example of how this has been a problem in the region is that outreach teams may come to a community for identification and assessment and then refer patients to their main hospital out of the region, rather than provide information about more local options where available services are located. Patients may not realise that there is an appropriate service provider nearby that they can access which would provide similar services at much less cost to them. Other conflicts and competition between professionals become evident when, for example, training is not respected or one person believes that another is not competent to do a task, even though there is evidence that he or she can and has been hired to do so. The patients end up suffering because even simple cases, like conjunctivitis that could be handled by the junior staff, are left for an ophthalmologist to see and the patients end up staying for long periods of time before being attended to.
The strategies we have used to enhance collaboration can be grouped into two main categories: (1) positive attitudes and innovations and (2) fostering personal relationships. We see positive attitudes as a primary way to highlight what we are aiming to achieve. These attitudes include being committed to collaboration, being patient- or client-focused, valuing interprofessional education, and being open to new technologies and ways of communication. Fostering a variety of personal relationships is a crucial strategy in our environment, where social networks are so important. Stronger personal relationships can nurture innovative strategies with colleagues, engage new energy and maintain momentum when obstacles seem overwhelming.
Maintaining a positive attitude is foundational to collaboration, and we have looked for ways to maintain our commitment to overcoming the barriers listed above. For example, we take time to recognise the impacts of hierarchy within our organisations and try to work with those who are ‘higher’ and ‘lower’ than we are to establish more equal relationships. We have used our personal money and time to meet; while this strategy is not sustainable over the long term it can be very effective in the short term. We have suggested colleagues for projects and opportunities have come up to work together. The new GRID Network is one example of a professional development opportunity and community of practice that we suggested others could join, although only a small number of practitioners can join due to the structural limitations of the project.
We have found that maintaining the attitude of being client-focused and aiming for the best possible client outcomes supports collaboration. Hence, if we look into the plight of the patient and focus on their outcomes, rather than making our financial profit the primary goal, we can work together in better ways. We strive to keep the patients’ welfare close to our hearts and we cooperate more for the clients’ interests, not our own.
The third attitude we are fostering is appreciation for early career and lifelong learning. In our educational systems the promotion of interprofessional education
Continuous professional education seminars for practitioners can be of great help in upgrading the knowledge of eye care personnel in the region. When a programme is being offered in one organisation, it can be opened up to other organisations. When one person takes a course, we look for ways to share the knowledge with other eye care practitioners in the region. We are beginning to work together to develop consensus statements about eye care, to train ourselves on how to use best practice guidelines, and to develop certification exams to keep up to date with international standards.
We value the attitude that as professionals we need to embrace and optimise technologies. New and older technologies are essential and unavoidable to a health system, as well as for professional collaboration. Over the past decade, phones and computers have become more affordable and available in our region. Telecommunication and information technologies have the potential to lead to telemedicine, which requires collaborative practice and can improve clinical health outcomes.
Within organisations, we use a number of strategies to build and strengthen relationships among staff members. These include the following:
Good relationships between healthcare providers are a necessity for quality healthcare services in the North-West Region. It is important for all stakeholders to know and communicate with each other so that they can know who is best in certain areas and to share ideas and learn from each other. Some of the strategies used to build institutional relationships include the following:
We recognise the importance of building relationships with administration. We build relationships in this domain by giving regular updates of successes and problems faced in our departments and by inviting administrators to our quarterly departmental meetings. In many institutions, the organisational administrators are not health or vision personnel and are continually learning about the context of healthcare. The eye care team may not be part of the management committee, are not invited to attend their meetings, and often have little or no opportunity for input. Meanwhile the administrators may not know what is needed to run the eye departments. At the end of the day, some important drugs, equipment and instruments may not be bought because the administrators did not see them as important. When there is a good relationship between the ophthalmologist and administration, the right things will be supplied at the right time and this will offer the desired quality care eye services.
Despite our progress, we know that there are more strategies that we would like to put in place but have not yet been able to implement. In this section we identify three: the development of a collaborative regional eye care programme (including a referral system) (see, for example, ideas for integration of eye care into primary care systems), with a strong continuing professional education programme, and more informative patient screening and education resources.
The development of a regional eye care programme is a goal that repeatedly comes up in our discussions. While there is a national strategic plan for eye health,
A regional eye care programme could promote effective referrals and facilitate professional education, include various stakeholders and their locations and competences, provide mechanisms to liaise with the traditional practitioners while weeding out the quacks and develop opportunities for a stronger research programme about our practices. A regional programme could reinforce that better care is about timely intervention and could offer primary eye care to patients who are very far from the main specialist hospitals. A regional programme would provide a fertile setting for professional development opportunities for training and career development of medical doctors, nurses and others in various government and non-governmental facilities. This programme could include a coordinator or coordination team for the region who would make supportive and supervisory visits. It could provide information, assistance and support to professional providers, particularly when challenging situations are encountered. Developing a good referral system and protocol whereby feedback could be shared after referring patients could be an effective innovation for quality improvement. This feedback loop would include sharing the contacts of colleagues working in other hospitals so that applicable calls concerning patient management could be made directly to appropriate services.
We aspire to have more and better continuing education opportunities for eye care providers in the North-West Region. For example, a meeting or forum could be held at least once a year to discuss and share experiences and best practices. Finding ways to mentor and support the more experienced senior eye care providers to assist the junior ones whenever need arises, even if they do not work in the same institution, is also important. For example, if a junior ophthalmologist intends to come and observe how a particular procedure is done, he or she should be welcomed, and the senior ophthalmologist should receive some recognition for mentoring or providing professional development services.
The development of patient education materials is an area ripe for more collaboration in our region as there is very little currently available. For example, there could be more public health resources such as a common summary on eye health shared to patients visiting the various eye departments.
In order to succeed in the prevention of blindness and in providing excellent eye care services in our region, we have learnt that we need to work together as a large team, even if we are located in different organisations. We follow the theme for World Sight Day 2016: ‘We are stronger together’.
There is clearly a need for more research to understand the benefits and, when appropriate, the drawbacks of collaboration in settings such as ours. We support the recommendations of others that health research could include an explicit focus on collaboration, including on ways to assess and measure it.
We have described what collaboration is in healthcare and how it benefits patients, professionals and health systems. Barriers and strategies for their amelioration have been identified. Without collaboration and cooperation, clients and patients are not offered quality healthcare and services; with collaboration we will have better vision care, avoid errors and ensure patients’ safety. Collaboration benefits healthcare providers by improving on knowledge and skills and therefore building up careers. Systems also benefit, through better outcomes and reductions in waste. For the North-West Region, we encourage all eye care practitioners to work together and become familiar with all of the services available, and all professionals working in health, social services and development to actively work towards improved collaboration. Our people deserve no less.
The authors thank Mr Jacques Chirac Awa for ongoing supervision of the GRID Network and for proofreading this article. The authors are thankful for the financial support from the Cameroon Baptist Convention Health Board and financial support for the GRID Network from CBM Australia and Australian Aid. They also thank Tamsyn Riddle for assistance in manuscript preparation.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Each of the authors made a significant contribution to the article. Much of the specific content was provided by M.O., J.S. and S.M.M., with additional contributions by L.M. and L.C. The article was developed by the first three authors, M.O., J.S. and S.M.M., based on their professional experiences as they found ways to improve collaboration among eye care professionals in the North-West Region of Cameroon. Writing support came from L.M. and L.C., who both have extensive experience in the North-West Region. The article was written using an iterative process that involved all authors. L.C. did most of the editing and formatting for submission for publication.
The authors thank the African Vision and Research Institute for financial assistance with the article page fees.